Healthcare Provider Details

I. General information

NPI: 1437378213
Provider Name (Legal Business Name): HAYS CISD WELL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 04/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3839 E FM 150
KYLE TX
78640-6072
US

IV. Provider business mailing address

21003 IH 35
KYLE TX
78640-4745
US

V. Phone/Fax

Practice location:
  • Phone: 512-268-5218
  • Fax: 512-268-5219
Mailing address:
  • Phone: 512-268-5218
  • Fax: 512-268-5219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number587900
License Number StateTX

VIII. Authorized Official

Name: MRS. RUTH ROBERTS
Title or Position: DIRECTOR
Credential: RN, MSN
Phone: 512-268-8474